Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sedgewood Commons during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently monitor or document medication refrigerator temperatures as required by CDC guidelines, with significant gaps in twice-daily temperature logs over a three-month period. This deficiency was confirmed through record review and staff interviews.
Surveyors found widespread deficiencies in housekeeping and maintenance, including off-track privacy curtains, misaligned closet doors, stained and damaged bathroom fixtures, and strong urine-like odors in multiple rooms and common areas. These issues compromised resident privacy and comfort, and were confirmed by facility leadership during an environmental tour.
An unsecured container of CaviWipes, a chemical cleaning product, was found on a bedside table in a resident's room. The SDS for CaviWipes details health hazards if improperly handled, and the product should not have been accessible in resident care areas, indicating a failure to maintain a hazard-free environment.
The facility failed to correct previously cited deficiencies, as surveyors again found that medication refrigerator temperatures were not monitored daily and that infection control protocols, specifically Enhanced Barrier Precautions, were not properly implemented. These issues persisted despite prior identification and a plan of correction.
A resident with a history of chronic diarrhea and prior C-diff colonization developed acute symptoms consistent with infectious diarrhea, but staff did not initiate transmission-based precautions or notify clinical leadership as required by policy. CNAs observed concerning changes but were told not to use precautions, and no signage or PPE was present. The Infection Preventionist and provider were unaware of the resident's condition until informed by surveyors, resulting in delayed infection control actions.
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
The facility failed to properly manage controlled substances, resulting in a medication error where a resident received another's morphine. The morphine bottle was not removed from use immediately, and the error was not documented. Additionally, controlled substances were logged by only one staff member, contrary to policy requiring two. This was confirmed by the Administrator and Unit Manager.
The facility failed to provide adequate housekeeping and maintenance services in two of three units. Observations included dirty shower chairs, cracked tiles, peeling wallpaper, and unlabeled urinals. The Director of Maintenance confirmed these findings.
The facility failed to complete annual performance evaluations for three CNAs. CNA #3, CNA #4, and CNA #5 had not received annual evaluations for multiple years, as confirmed by the Administrator, Clinical Market Advisor, and Market President.
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators. In the [NAME] House, a dormitory-style refrigerator with a freezer was used to store vaccines, and an out-of-range temperature was recorded without appropriate follow-up actions. In the [NAME] House, two opened and unlabeled vials of PPD were found, and the refrigerator had significant ice buildup, leading to incorrect storage of various vaccines.
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. A surveyor observed dust, debris, and staining on ceiling vents, and a sticky, dusty film on flat surfaces. Additionally, there was no documentation of food temperatures being taken during several meals.
The facility failed to provide residents and/or their representatives with the required Vaccine Information Statements (VIS) for the pneumococcal vaccines (PCV13, PCV15, and PCV20) prior to immunization. The omission was confirmed by the Infection Preventionist and the Marketing Clinical Advisor, who acknowledged that only the VIS for PPSV23 was being provided.
The facility failed to ensure residents and their representatives received education on the benefits, risks, and side effects of the COVID-19 vaccine before immunization. Additionally, staff were not provided formal education on the vaccine. The Infection Preventionist, Nurse Practice Educator, and Marketing Clinical Advisor confirmed the lack of educational materials and documentation, leading to the identified deficiency.
The facility failed to provide required training on Resident Rights for two CNAs, as confirmed by the Clinical Market Advisor. Both CNAs, hired in December 2023, had no documented training on this essential topic.
The facility failed to coordinate PASRR Level I and Level II assessments for a resident with Dementia and PTSD. The clinical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority. This was confirmed by the facility's Social Worker during an interview.
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. A resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that MDS Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker.
The facility failed to meet the personal hygiene preferences for a resident dependent on staff for ADL. The resident was observed with an unshaven face and long fingernails, despite expressing a preference for being clean-shaven. The CNA and Unit Manager confirmed the lack of specific documentation for completed nail care or shaving.
A facility failed to provide appropriate treatment for a resident's skin condition, as nursing staff did not identify or document a rash despite the resident's representative bringing in a cream from a dermatologist. The care plan's instructions to observe and report skin abnormalities were not followed, and the issue was only addressed after surveyor intervention.
The facility's Quality Assurance Committee failed to ensure the effectiveness of the POC for a deficiency related to housekeeping and maintenance services. Despite the POC, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms, leading to the recitation of the same deficiency tag F584.
Failure to Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to consistently monitor and document temperature controls for medication and vaccine refrigerators in two medication storage rooms. During observations, it was noted that these refrigerators contained various vaccines and multi-use vials, including Pneumococcal 20, influenza vaccinations, and Tuberculin Purified Protein. Review of the facility's temperature logs for the months of March, April, and May revealed significant gaps in documentation, with many days lacking evidence of the required twice-daily temperature readings. Specifically, one refrigerator was missing readings for 15, 24, and 25 days in March, April, and May, respectively, while another refrigerator was missing readings for 31, 28, and 30 days in the same months. During interviews, facility staff confirmed the findings and stated that they follow CDC guidelines for vaccine and medication storage, which require temperature checks and documentation at least twice daily. The lack of consistent temperature monitoring and documentation was confirmed by both the surveyor's review and staff interviews, indicating noncompliance with accepted professional standards and CDC guidelines for medication and vaccine storage.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain adequate housekeeping and maintenance services, resulting in unsanitary, disordered, and uncomfortable conditions in 36 out of 56 resident rooms and across all three units. Specific deficiencies included room divider curtains and window curtains being off track and unable to fully close, which compromised resident privacy in multiple rooms. Additionally, closet doors were misaligned and did not fully close in several rooms. Other maintenance issues included holes in walls, torn wallpaper, stained ceiling tiles, and damaged bathroom fixtures such as chipped sink countertops and toilets with visible stains or improper installation. Several rooms and common areas were noted to have strong urine-like odors and uncleanable surfaces due to damage or staining. These findings were confirmed during an environmental observation tour conducted with the Administrator and Maintenance Supervisor, who acknowledged the extent of the issues. The report documents that these conditions were present throughout the facility, affecting a significant number of resident rooms and common areas, and were not limited to isolated incidents. No information was provided regarding the medical history or specific conditions of the residents affected by these deficiencies.
Unsecured Chemical Cleaning Product Found in Resident Room
Penalty
Summary
A deficiency was identified when an unsecured container of CaviWipes, a chemical cleaning product, was observed on a bedside table in a resident's room. This incident occurred during a survey of one of the facility's units. The Safety Data Sheet (SDS) for CaviWipes outlines the potential health hazards associated with exposure, including the need for medical attention in cases of inhalation, skin contact, eye contact, or ingestion. The presence of this unsecured chemical in a resident care area demonstrated a failure to ensure that the environment was free from accident hazards related to the proper storage of chemicals.
Repeat Deficiencies in Medication Storage and Infection Control
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. During a follow-up survey, it was found that the same deficiencies, specifically F761 and F880, were still present. F761 involved the failure to monitor medication refrigerator temperatures on a daily basis, while F880 pertained to the failure to maintain an Infection Control Program by not applying appropriate interventions related to Enhanced Barrier Precautions. These deficiencies were observed and confirmed through record review and interviews, and were discussed with facility leadership during the exit conference.
Failure to Implement Timely Infection Control Measures for Suspected C-diff
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for the surveillance and prevention of gastrointestinal disease transmission in one resident. Despite facility policy requiring nursing staff to initiate transmission-based precautions for suspected infectious diarrhea and to notify the attending physician and Infection Preventionist, these steps were not followed when a resident exhibited three episodes of watery stool with significant mucous and foul odor. Certified Nursing Assistants observed changes in the resident's stool consistent with previous C-diff infection but were instructed not to use transmission-based precautions, and no signage or personal protective equipment was present outside the resident's room. The resident, who had a history of chronic diarrhea and prior C-diff colonization, was not placed on precautions despite acute changes in stool characteristics. Interviews with staff revealed confusion and lack of communication regarding the need for precautions, with CNAs expressing uncertainty about protocol and reporting that they were not informed of the resident's change in condition. The Infection Preventionist and Market Clinical Advisor were unaware of the resident's acute symptoms until informed by surveyors, and the facility provider confirmed that the changes in stool warranted precautions and further testing, but they had not been notified. The failure to recognize and respond to the resident's symptoms in a timely manner resulted in a delay in implementing appropriate infection control measures.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Medication Management Deficiency Involving Controlled Substances
Penalty
Summary
The facility failed to maintain a proper system for handling controlled substances, leading to a medication error involving two residents. A nurse administered a dose of morphine to one resident using another resident's morphine bottle and oral syringe. This incident was not documented in the Narcotics Logbook, and the morphine bottle continued to be used for six days after the error occurred. The Unit Director was unaware that the morphine bottle had not been removed from use immediately, and there was no evidence that the oral syringe was disposed of after the incident. Additionally, the facility did not comply with its policy requiring two licensed staff members to document the receipt of controlled substances from the pharmacy. The Narcotic Logbook showed that controlled substances, including morphine and fentanyl patches, were logged in by only one staff member on multiple occasions. This was confirmed by the Administrator and the Unit Manager, indicating a systemic issue in the management of controlled drugs at the facility.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for two of three units. During an environmental tour, several deficiencies were observed. In the first unit, the shower room had a laydown shower chair with an orange-colored coating under the chair edge and rim, a raised floor with cracks, and cove base peeling away from the wall. A resident's wheelchair seat was coated with dirt and debris. One bedroom door was sticking, making it difficult to open, and a wall light near another room door was missing its cover. Wallpaper was peeling and stapled to the wall in multiple locations. In the second unit, the shower room had a bariatric shower chair and laydown shower chair both with orange-colored coating under the chair edge and rim. One bathroom had cracked tiles and a black built-up substance around the base of the toilet. Another bathroom had a urine hat stored on top of the toilet, and a shared bathroom had an unlabeled urinal hanging on the toilet grab bars. The Director of Maintenance confirmed these findings during the tour.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled Certified Nursing Assistants (CNAs). CNA #3, hired on 3/4/20, had their last performance evaluation as a 90-day progress report completed on 8/14/20, with no evidence of annual evaluations for 2021, 2022, 2023, or 2024. CNA #4, hired on 5/11/15, had their last performance evaluation completed on 5/3/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. CNA #5, hired on 7/31/18, had their last performance evaluation completed on 9/26/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. During an interview on 3/27/24, the Administrator, Clinical Market Advisor, and Market President confirmed that staff performance evaluations had not been completed annually.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators surveyed. In the [NAME] House medication room, a dormitory-style refrigerator with a freezer was used to store influenza and pneumococcal vaccines. The recorded temperature for the refrigerator showed an out-of-range temperature of 70.8°F on 3/24/24. The Unit Manager was unaware of any actions taken following the discovery of the out-of-range temperature and could not confirm whether the vaccines were in the refrigerator at that time. Additionally, the Interim Director of Nursing (IDON) confirmed that the dorm-style refrigerator was inappropriate for storing vaccinations and that the vaccines were not removed at the time the out-of-range temperature was discovered. In the [NAME] House medication room, a surveyor found two opened and unlabeled vials of Purified Protein Derivative (PPD) used for tuberculosis testing, which should have been labeled with an open date and discarded 30 days after opening. The refrigerator also had significant ice buildup along the back inside surface and stored various vaccines, including pneumococcal, RSV, Spikevax (Covid-19), and influenza vaccines. The IDON confirmed the ice buildup and that the facility policy was not followed after the discovery of the out-of-range temperature, leading to incorrect storage of vaccinations. The facility's policy required immediate notification of maintenance and the Director of Nursing, moving medications to another refrigerator, and contacting the pharmacist for guidance, none of which were followed.
Kitchen Sanitation and Food Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. During an initial kitchen tour, a surveyor observed and confirmed with the cook the presence of dust, debris, and staining on the ceiling vents, as well as a sticky, dusty film on all flat surfaces in the kitchen. Additionally, there was a lack of documentation of food temperatures being taken during dinner on 3/23/24, all day on 3/24/24, all day on 3/25/24, and breakfast on 3/26/24.
Failure to Provide Required Vaccine Information Statements
Penalty
Summary
The facility failed to provide residents and/or their representatives with the Vaccine Information Statement (VIS) prior to administering the pneumococcal vaccine (Prevnar). The facility's Pneumococcal Vaccination policy and procedure, revised on 11/1/23, mandates that patients or their representatives be educated about the benefits and potential side effects of the vaccination through the VIS. However, during a review of the facility's admission packet, it was found that the VIS sheets for PCV13, PCV15, and PCV20 were missing. The Infection Preventionist (IP) confirmed that the required VIS sheets were not provided to residents or their representatives upon admission or prior to the administration of these vaccines. Further interviews revealed that the facility's Marketing Clinical Advisor also confirmed the omission of the Prevnar vaccine VIS sheets. The facility was only providing the Pneumococcal Polysaccharide vaccine (PPSV23) VIS sheet, neglecting to include the necessary VIS sheets for the other pneumococcal vaccines (PCV13, PCV15, and PCV20). This oversight led to residents and/or their representatives not receiving the required information about the risks and benefits of the vaccines before immunization.
Failure to Provide COVID-19 Vaccine Education to Residents and Staff
Penalty
Summary
The facility failed to ensure that each resident or their representative received education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine before immunizing residents. The facility's Infection Preventionist (IP) confirmed that the admission packet, which includes the COVID-19 vaccine education and consent form, lacked evidence of such education. Additionally, the IP admitted that staff were not provided formal education on the benefits and risks of the COVID-19 vaccine. This was corroborated by the Nurse Practice Educator (NPE), who stated that no education on COVID-19 vaccines had been conducted for staff, and a Registered Nurse (RN) in orientation confirmed she had not received any education on the new Spikevax COVID-19 vaccine. A Licensed Practical Nurse (LPN) also indicated uncertainty about receiving education on the new vaccine, typically only signing sheets when new information is released. The Marketing Clinical Advisor confirmed that residents and their representatives were not provided with the Vaccine Information Statement (VIS) education upon admission or prior to vaccine administration, and no educational materials were found in common areas of the facility. The facility's COVID-19 Vaccination policy and procedure, revised on 2/7/24, states that the facility will provide the opportunity to receive COVID-19 vaccinations following CDC recommendations and will obtain consent using the Patient Informed Consent or Declination COVID-19 form. However, the facility did not adhere to this policy, as evidenced by the lack of documented education for both residents and staff. The surveyor's interviews with various staff members, including the IP, NPE, RN, and LPN, revealed a consistent lack of formal education on the COVID-19 vaccine, specifically the new Spikevax vaccine. The Marketing Clinical Advisor's confirmation further highlighted the facility's failure to provide necessary educational materials to residents and staff, leading to the identified deficiency.
Lack of Resident Rights Training for CNAs
Penalty
Summary
The facility failed to implement and maintain an effective training program that includes training on Resident Rights for two of five Certified Nursing Assistants (CNAs) reviewed. Specifically, CNA #1, hired on 12/26/23, and CNA #2, hired on 12/4/23, had no documented training regarding Resident Rights. This deficiency was confirmed during an interview with the Clinical Market Advisor, who acknowledged the absence of documentation for the required annual training on Resident Rights.
Failure to Complete PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments for Pre-Admission Screening and Resident Review (PASRR) Level I and Level II programs for a resident diagnosed with Dementia and Post Traumatic Stress Disorder. The clinical record for the resident, who was admitted to the facility, lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. This deficiency was confirmed during an interview with the facility's Social Worker, who acknowledged that the PASRR Level I screening had not been completed and stated they would proceed with the PASRR at that time. The finding was later discussed with the Market President.
Failure to Review and Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. During an interview, a resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that Minimum Data Set (MDS) Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker during an interview.
Failure to Meet Personal Hygiene Preferences for Dependent Resident
Penalty
Summary
The facility failed to meet the personal hygiene preferences for a resident who is dependent on staff for Activities of Daily Living (ADL). On 3/26/24, a surveyor observed Resident #49 with an unshaven face and long fingernails with a dark substance under them. The resident, diagnosed with dementia and lower extremity amputation, was assessed to need staff assistance for personal hygiene, including nail care and shaving, as per the Minimum Data Set (MDS) assessment. The Certified Nursing Assistant (CNA) confirmed that the resident had not been shaved for several days and was unsure about the last time the nails were done, acknowledging the resident's dependence on staff for these tasks. On 3/27/24, the surveyor interviewed Resident #49 and the Resident Representative, who confirmed that the resident had still not been shaved or provided nail care. The resident expressed a preference for being clean-shaven, and the Resident Representative mentioned having requested shaving several days prior. The Unit Manager confirmed that there was no specific documentation for completed nail care or shaving, only for refusals, and there was no record of the resident refusing these services. The Unit Manager acknowledged that residents should be shaved daily if that is their preference.
Failure to Provide Appropriate Skin Condition Treatment
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for skin conditions. The deficiency was identified for a resident who had a rash and was observed scratching and itching several small, scabbed areas on the upper right arm. Despite the resident's representative bringing in a cream from a dermatologist, there was no evidence in the resident's skilled documentation from admission through the observation period that the nursing staff had identified or documented the rash. The care plan instructed nursing to observe the skin condition daily and report abnormalities, but this was not followed. The RN confirmed she was unaware of the rash and noted that skin checks are done weekly, relying on CNAs to report any concerns. The RN also acknowledged the need for a provider order to use the cream brought in by the family. The interim Director of Nursing confirmed that the resident's rash was only assessed after surveyor intervention. The lack of documentation and timely assessment of the resident's skin condition indicates a failure to provide appropriate treatment and care according to the resident's needs and the facility's care plan. This deficiency highlights a gap in communication and adherence to care protocols within the facility's nursing staff.
Failure to Maintain Sanitary Conditions
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for a deficiency identified during the annual Long Term Care Recertification Survey. The deficiency, cited under Federal citation F584, pertained to the facility's failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. Despite the POC indicating that resident rooms and bathrooms would be in a sanitary condition by a specified completion date, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms on the [NAME] unit. These observations led to the recitation of the same deficiency tag F584.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Falmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fallbrook Commons | 3.9 mi | ★★★★★ | 0 | 0 |
| Brentwood Center For Health & Rehabilitation, Llc | 3.9 mi | ★★★★★ | 23 | 0 |
| Cedars Nursing Care Center | 4 mi | ★★★★★ | 1 | 0 |
| Seaside Healthcare Llc | 4.4 mi | ★★★★★ | 13 | 0 |
| Coastal Manor | 4.9 mi | ★★★★★ | 36 | 0 |
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